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Cost & Quality Problems

Low-Value Care

 

Every year millions of Americans receive low-value healthcare: treatments, tests, and procedures that are either wasteful or ineffective.  Examples include: 

  • Receiving an MRI for a nonspecific backache

  • Prostate-specific antigen (PSA) testing for men over age 75

  • Head imaging (CT or MRI) for uncomplicated headache

  • Getting an antibiotic prescribed for a viral infection

As a result of low-value care, patients are exposed to unnecessary risks that fail to improve their health and in some cases cause them harm. Wasteful spending on low-value care ultimately contributes to the high cost of healthcare that we all pay. 

How Common is it?

We lack a standard definition of low-value care and our tools for measuring low-value care are imprecise. In fact, lack of universal standards for defining low-value care was identified as a major gap in our research gaps report.

A general definition: Low-value care is the use of an intervention where evidence suggests it confers little or no benefit on patients, or where the risk of harm exceeds the likely benefit.

While waste is often described as representing up to one third of healthcare spending, the IOM’s definition of waste is broader than low-value care. Looking at just low-value care, the IOM estimated that 14 percent of all healthcare spending is for unnecessary and inefficient services.1

A handful of organizations have worked to identify specific forms of low-value care.  The American Board of Internal Medicine Foundation (ABIM) has partnered with Consumer Reports and over 70 medical specialty societies for its Choosing Wisely initiative.  The goal of the initiative is to promote conversations between physicians and patients that help patients choose evidence-based treatments while avoiding care that is wasteful and unnecessary.2 To this end, the program has released lists identifying over 400 treatments and tests whose effectiveness should be questioned in certain circumstances.  Similar efforts have been undertaken by the U.S. Preventive Services Task Force (services rated “D”) and the National Institute for Health and Care Excellence ("do not do" recommendations) in the UK.   Low-value care has also been identified in Health Assessments performed by the Canadian Agency for Drugs and Technologies and various peer-reviewed medical journals.

There is a gap between our ability to identify low-value services and our ability to establish the frequency of these services in claims data.  Because there can be a high degree of clinical nuance when working with individual patients, a much smaller subset of low-value services is typically used by researchers working with claims data.3 For this reason, most studies underestimate the true prevalence of low-value care.

Several researchers have found that the use of these services varies greatly across providers and regions. Nonetheless, low-value care touches many patients.  A study of just 26 low-value services found that 42% of Medicare beneficiaries had received at least one low-value service, although a second study found much lower prevalence among the commercially insured for a similar subset of services.4  Some low-value services are relatively common. For instance, the over-prescription of antibiotics, which contributes to high costs and growing antibiotic resistance, is highly prevalent, with the CDC estimating as many as half of all antibiotic prescriptions are unnecessary or ineffective.5 Similarly, providing opioids to patients with migraine headaches and using antipsychotics to treat dementia, are two low-value services that are prescribed to as many as a quarter of all patients who have the relevant diagnosis.  Others services, such as unnecessary cervical cancer screenings, are far more rare.6

Strategies to Address Low-Value Care

In order to reduce the use of low-value care, we must have some consensus around the list of  low-value services, provide accurate information to both physicians and patients regarding the risks of these services, and consider financial and non-financial incentives to discourage their use.

One of the most ambitious efforts in this regard has been the aforementioned Choosing Wisely campaign.  For over four years, the initiative has aimed to educate providers and patients about treatments that are potentially wasteful or unnecessary.    

More recently, Academy Health has partnered with the ABIM Foundation to spearhead a multi-stakeholder effort aimed at accelerating the research that is required to identify low-value services.

Alternative payment models, such as Accountable Care Organizations (ACOs), are also targeting low-value services as they shift away from traditional fee-for-service payments programs and towards those that pay for performance rather than volume.  A recent study found that Pioneer ACOs were more effective at reducing the use of low-value services when compared to a control group.

Value-Based Insurance Design (VBID) is also being explored to discourage the use of low-value care.  VBID has traditionally lowered the patient’s cost-sharing requirements in order to encourage the consumption of high-value care.  Largely untested is whether  raising cost-sharing requirements for services that are considered low-value is needed to reduce the use of these services. It may be more effective to work directly with providers to ensure that low-value services aren’t even recommended in the first place.

Next Steps for Advocates, Policymakers and Researchers 

Efforts to target and discourage the use of low-value services are complicated by incomplete evidence regarding the clinical effectiveness of various treatments. As many as half of all common treatments lack sufficient evidence of their effectiveness. In order to make informed decisions, physicians and patients need to know the risks and benefits associated with a given treatment. This is especially challenging given the diversity of patient populations: what may be low-value for some may be valuable for others. Therefore: 

  • While progress has been made in identifying low-value services, we must continue to build a robust evidence base regarding the clinical effectiveness of treatments. This is fundamental to identifying low-value treatments.
  • Even when evidence is available, physicians and their patients are too often unaware.  New research is needed to understand how to do more effective dissemination and how to foster informed, shared conversations between physicians and patients.
  • The value of financial and non-financial incentives to discourage low-value care will likely be important but additional study is needed on when to use and how to align across other incentives facing providers.

Notes

1. The more widely known figure of ⅓ of all spending being waste includes forms of waste other than low-value care such as excess administrative costs, inflated prices, fraud, and prevention failures. Institute of Medicine. Best care at lower cost: the path to continuously learning health care in America. Washington, DC: National Academies Press, 2012. http://www.iom.edu/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning -Health-Care -in-America.aspx

2. The ABIM Foundation's campaign was not intended to inform cost-containment efforts and quality measures.  As testimony to its careful design, the initiative does not appear to be generating concern about rationing or undermining the patient–doctor relationship, a potential concern. http://www.nejm.org/doi/full/10.1056/NEJMp1314965#t=article

3. For example, one study looked at 28 different low-value services and found the most common to be triodothyyronine measurement in hypothyroidism, imaging for nonspecific back pain, and imaging for uncomplicated headache.  The largest proportion of spending was on spinal injections for lower-back pain. (Parks, A., & O’Malley, P.  Low-Value Health Care Services in a Commercially Insured Population.  JAMA Internal Medicine, 176(10), p.1567-72).  A similar study of Medicare beneficiaries looked at just 26 low-value services and found the prevalence associated with them to range from 1.2% to 46.5%.   (Colla, C. et. al. (2015).  Choosing Wisely: Prevalence and Correlates of Low-Value Health Care Services in the United States. Journal Of General Internal Medicine, 30(2), p.221-8, doi:10.1007/s11606-014-3070-z)  

4. Schwartz, BA, et al. (2014). Measuring Low-Value Care in Medicare. JAMA Internal Medicine, 174(7), 1067-1076, doi:10.1001/jamainternmed.2014.1541.  In the commercial population: Parks, A., & O’Malley, P.  Low-Value Health Care Services in a Commercially Insured Population.  JAMA Internal Medicine, 176(10), p.1567-72

5. Antibiotic Resistance Threats in the United States, 2013. The Centers for Disease Control and Prevention.

6. Colla, C. et. al. (2015).  Choosing Wisely: Prevalence and Correlates of Low-Value Health Care Services in the United States. Journal Of General Internal Medicine, 30(2), p.221-8, doi:10.1007/s11606-014-3070-z